ndis service agreement form

NDIS Service Agreement

1. Parties

This Service Agreement is for:

First Name *

Last Name *

Client Date Of Birth *

NDIS Number *

a participant in the National Disability Insurance Scheme (client), and is made between:

Client Representative Name *

Company Name *

Date *

2. The NDIS and this Service Agreement

This Service Agreement is made for the purpose of providing supports under the clients NDIS plan.

The parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:

support the independence and social and economic client of people with disability; and
enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.

3. Schedule of supports

The Health Psychology Clinic agrees to provide the client Psychology Assessment and Therapy services. The supports and their prices are indexied to the NDIS Price Guide for these services and set out in the attached Schedule of Supports. Therapy and assessment services are GSTexclusive . Other servies where required are GST inclusive (if applicable). Additional expenses (i.e. things that are not included as part of a client NDIS supports) are the responsibility of the client / clients representative and are not included in the cost of the supports.

4. The Health Psychology Clinic Responsibilities

The Health Psychology Clinic agrees to:

review the provision of supports at least annually with the client;
once agreed, provide supports that meet the client's needs at the client's preferred times;
communicate openly and honestly in a timely manner;
treat the client with courtesy and respect;
consult the client on decisions about how supports are provided;
give the client information about managing any complaints or disagreements and details of The Health Psychology cancellation policy;
listen to the client’s feedback and resolve problems quickly;
give the client a minimum of 24 hours notice if The Health Psychology Clinic has to change a scheduled appointment to provide supports;
give the client the required notice if The Health Psychology Clinic needs to end this Service Agreement (see "Ending this Service Agreement" below for more information);
protect the client's privacy and confidential information;
provide supports in a manner consistent with all relevant laws, including the NDIS Act 2013 and Rules, and the Australian Consumer Law;
keep accurate records on the supports provided to the client; and
will issue invoices and statements of the supports delivered to the participant as per the NDIA Terms of Business for Registered Providers as requested

5. Responsibilities of the client / client representative

The client / client representative agrees to:

inform The Health Psychology Clinic about how they wish the supports to be delivered to meet the client needs;
treat The Health Psychology Clinicworkers with courtesy and respect;
talk to The Health Psychology Clinic if the client has any concerns about the supports being provided;
give The Health Psychology Clinic the required notice if the client cannot make a scheduled appointment, noting that if the notice is not provided , The Health Psychology Cliniccancellation policy will apply;
give The Health Psychology Clinic the required notice if the client needs to end this Service Agreement (see 'Ending this Service Agreement' below for more information); and
let The Health Psychology Clinic know immediately if the client NDIS plan is suspended or replaced by a new NDIS plan, or the client stops being a participant in the NDIS.

6. Payments

The Health Psychology Clinic will seek payment for their provision of supports after the supports have been delivered.

SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, [Practice Name] will send the client / client representative an invoice for those supports for the client / client representative to pay. The client / client representative will pay the invoice by direct debit / EFT within 7 days. NDIA MANAGED - The client has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports, [Practice Name] will claim payment for those supports from the NDIA. PLAN MANAGED - The client has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, [Practice Name] will claim payment for those supports from

Plan Manager Provider Name

Plan Manager Email Address

Start Date

To whom should invoices be sent ? *

7. Changes to this Service Agreement

If changes to the supports or their delivery are required, the parties agree to discuss and review this Service Agreement. The parties agree that any changes to this Service Agreement will be in writing, signed and dated by the parties.

8 Ending this Service Agreement

Should either party wish to end this Service Agreement they must give 2 weeks notice. If either party seriously breaches this Service Agreement the requirement of notice will be waived.

9. Feedback, complaints and disputes

If the client wishes to give The Health Psychology Clinic feedback or is not happy with the provision of supports and wishes to make a complaint, the participant can talk to Dr. Belinda Thewes on 0490 819 492 or email belinda@healthpsychclinic.com.au

If the client is not satisfied or does not want to talk to this person, at any time, they can make a complaint to the NDIS Commission. Complaints to the NDIS Commission can be lodged:

online at www.ndiscommission.gov.au; or
by phone on: 1800 035 544.

10. Goods and Services Tax (GST)

For the purposes of GST legislation, the Parties confirm that:

a supply of supports under this Service Agreement is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the NDIS Act, in the client's NDIS Plan currently in effect under section 37 of the NDIS Act;
the client's NDIS Plan is expected to remain in effect during the period the supports are provided; and
the client / client representative will immediately notify the provider if the client's NDIS Plan is replaced by a new plan or the client stops being a participant in the NDIS.

11. Cancellation Policy

At The Health Psychology Clinic we value consistent and high quality intervention. If you need to cancel an appointment it is recommended it occur before 3pm on the day before your appointment to avoid a cancellation fee. If you contact The Health Psychology Clinic after 3pm the day before your appointment or on the day of your appointment there will be a cancellation fee of 90% charged to your account and payment due at your next appointment. If receiving a service at home, should your therapist arrive at your scheduled appointment and you are not at home or at the location of the appointment with no prior notice, the scheduled session including travel will be charged at 100% of the scheduled fee for that session. Where The Health Psychology Clinic cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party.Where multiple cancellations or no shows occur in a 12-month period, The Health Psychology Clinic will initiate contact with the participant and/or their nominee or support networks to establish if the supports we are providing are suitable or if you wish this service to be terminated.

I have read & understood the cancellation policy *

12. Contact details

The Client Representative can be contacted on:

Client Name

Client representative /Alternate contact person

Address *

Client Phone *

Client's email *

Email Address of Client Representative *

The Health Psychology Clinic can be contacted on:

Director: Dr. Belinda Thewes

belinda@healthpsychclinic.com.au

0490819492

13. Schedule of supports

I/we agree to pay for treatment/ therapy sessions provided by [Practice Name] through claiming against the National Disability Insurance Scheme (NDIS) service plan. Working with the NDIS we have been allocated physiotherapy funding for the service year (enter service dates)

Start Service Date *

Finish Service Date *

The Provider agrees to provide the client psychology services for the duration of the agreement at the scheduled rate. These include

Psychological assessment and treatment
Clinically relevant communications including phone calls/written programs/communication with other health professionals (any task that takes more than 10 minutes will be invoiced)
Attendance at team meetings/case conferences
Any reports, forms or letters as required by the NDIS or requested by the client / client representative
Cancellation charges for late notice or no show appointments

The Health Psychology Clinic reserves the right NOT to provide service or to cancel any future appointments for the client if you do not have sufficient funds in your plan or the plan expires. Any service fees not met by NDIS will be covered by the client / client representative.

Frequency of support *

WeeklyFortnightlyMonthly As scheduled

Where the support will be provided *

TelehealthHomevisitOther location

The total funding claimed by this service over the period of this service agreement will be

Total Funding Available for Psychology Assessment and Therapy Services

Price & Payment Information

Therapy and travel will be charged at the standard NDIS Price Guide rate of $214.00 per hour. Where therapy is delivered at home visits, a total of up to 60 mins per session will be charged for provider travel at the standard NDIS Price Guide rate.

Name of NDIS Support Category to which you would like services charged?

14. Agreement signatures

The parties understand and agree to the terms and conditions of this Service Agreement.

Signature of Client or Client Representative *

Draw signature|Type signatureClear

Name of Client Representative *

Signed Date *

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